Liver Disease and Hepatitis

• Liver disease and Hepatitis

Liver

• Largest internal organ
• Found below the diaphragm in the upper right abdominal quadrant
• Largest gland in the body, secreting bile that is stored in the gall bladder
• It can regenerate the whole liver even from as little as 26% of the original tissue

Liver Function

• Filters and cleans blood
• Metabolizes sugars, proteins, and fats
• Stores vitamins A, D, E, K, and B12
• Produces bile, crucial for fat digestion and the absorption of fat-soluble vitamins
• Stores minerals like iron and copper
• Removes metabolic byproducts and toxins from the blood
• Fights infections by capturing and digesting bacteria, fungi, parasites, and cellular debris
• Converts glucose into glycogen for storage in the liver
• Regulates glucose and cholesterol levels
• Produces essential proteins like blood clotting factors, albumin, and hormones
• Supports normal hemostasis by producing thrombopoietin, which stimulates bone marrow
• Breaks down hemoglobin, cholesterol, proteins, sex steroids, and various drugs

What Causes Liver Damage

• The liver has the ability to renew and repair itself up to a certain extent
• Damaged by alcohol

Alcohol and Liver Damage

• The liver filters alcohol to break it down and eliminate it from the body
• Liver cells die in the process
• The liver requires breaks from alcohol to regenerate and create new cells
• Increased alcohol consumption over a long period can cause the liver to be unable to recover, resulting in serious and permanent damage

Three Stages of Alcohol-Related Liver Disease

• Alcoholic fatty liver disease: often without symptoms and reversible
• Alcoholic hepatitis: inflammation of the liver, reversible in early stages
• Cirrhosis: irreversible scarring (fibrosis) of the liver, preventing normal function, and can lead to liver failure

Cirrhosis Symptoms

• Often no symptoms
• Tiredness and weakness
• Nausea and loss of appetite
• Weight loss
• Loss of libido
• Spider naevi
• Finger clubbing
• Sialosis
• Palmer erythema
• Swollen legs
• Jaundice
• Itchy skin
• Darker urine
• Bleeding
• Liver cancer

Cirrhosis Treatment

• Not possible to cure, focusing instead on management
• Lifestyle changes: no alcohol, diet, lose weight, stop smoking
• Medication: diuretics, beta blockers, and creams for itchy skin
• Liver transplant

Nonalcoholic Fatty Liver Disease

• Build-up of fat in the liver
• Not caused by alcohol
• Usually related to obesity
• Develops over many years
• Early stages are often symptom-free and cause no harm
• Can lead to liver inflammation, fibrosis, abdominal pain, tiredness, weight loss, weakness, and cirrhosis
• High levels of fat in the liver are associated with diabetes, hypertension, and liver disease

Primary Biliary Cirrhosis

• The immune system mistakenly attacks bile ducts
• Bile builds up in the liver, leading to cirrhosis
• Symptoms: bone and joint aches, fatigue, itchy skin, dry eyes and mouth, and abdominal pain
• Treatment: ursodeoxycholic acid and obeticholic acid, along with medications to relieve symptoms
• If untreated: osteoporosis, portal hypertension, ascites, vitamin deficiency, and liver cancer

Tumors and Cysts

• Primary liver cancer: hepatocellular carcinoma
• Secondary cancer: metastatic cancer from other organs
• Liver cysts: malformation of bile ducts
  • Congenital: polycystic liver disease caused by the parasite echinococcus

Haemochromatosis

• Inherited condition: iron overload that damages the liver, joints, pancreas, and heart
• More likely to develop liver cancer
• Treated with phlebotomy and chelating agents

Viral Hepatitis

• A viral infection of the liver
• Caused by hepatitis viruses A, B, C, D, and E
• Most relevant to dentistry are Hepatitis A, B, and C

Hepatitis A

• Caused by the hepatitis A virus
• Spread through the fecal-oral route, such as consuming food or drink contaminated with feces from an infected person
• Common in countries with poor sanitation
• Symptoms pass within a few months
• No specific treatment, but preventable by vaccination

Hepatitis B

• Caused by the hepatitis B virus
• Common infection worldwide
• Spread in blood of infected person
• Spread from infected pregnant women to baby
• Can be spread through unprotected sex, needle sharing in drug use, needle stick injuries, and sharing razors or toothbrushes
• 5% become chronic carriers
• Some develop cirrhosis and liver cancer
• Persists for years leading to liver damage in children
• 90% of infected babies develop chronic hepatitis
• Vaccination for all healthcare workers

Concentration of Hepatitis B Virus in Body Fluids

• Low or not detected in urine, feces, sweat, tears, and breast milk
• High in blood, serum, and wound exudates
• Moderate in semen, vaginal fluid, and saliva

Hepatitis B Transmission

• Very infectious and spreads more easily than HIV
• Can live outside the human body for up to 7 days
• Chronic Hep B causes large amounts of virus in blood
• After a needlestick injury, the risk of infection is 1 in 3 if not vaccinated

Hepatitis B Pathogenesis

• Incubation period: 45 to 180 days, with an average of 60 days
• Enters hepatocytes via blood
• The immune response to viral antigens expressed on the hepatocyte cell surface is responsible for the clinical syndrome
• 5% become chronic carriers
• Hep B surface antibody probably confers lifelong immunity

Hepatitis B Symptoms

• May be asymptomatic
• Tends to develop over 2-3 months
• Flu-like symptoms: tiredness, fever, aches and pains, loss of appetite, nausea, diarrhea, gastric pain, and jaundice
• Symptoms usually pass within 1-3 months in acute cases Chronic cases can last for up to 6 months or more

Hepatitis B Diagnosis

• Blood testing-serological tests
• Hep B antigens
• Hep B antibodies-used to document recovery and/or immunity to HBV infection
• Virus persists at low levels even after recovery
• Reactivation can occur spontaneously

Hepatitis B Treatment

• Emergency: dose of Hep B vaccination and dose of immunoglobulin
• Acute Hep B: rest, analgesia, and symptom relief
• Chronic Hep B: peginterferon alfa-2a stimulates the immune system to attack the Hep B virus, given via weekly injections Antiviral medication

Hepatitis B Prevention

• Vaccination
• Vaccination schedule: 3 doses at months 0, 1, and 6
  • Immune response: 60% after dose 1 and 95% after 3 doses
  • Duration of protection: over 15 years
• Hep B immunoglobulin

Hepatitis C

• Single-stranded RNA virus
• Pathogenesis, symptoms, and routes of transmission are the same as Hep B
• No vaccine against Hepatitis C
• Long-term effects include cirrhosis, liver failure, and liver cancer

Dental Aspects of Liver Disease

• Dental findings in Liver Disease

Dental Findings in Liver Disease

• Alcoholic cirrhosis: poor oral hygiene, dental neglect, and dental erosion from acid reflux
• Sialosis/parotid enlargement
• Gingival enlargement if the patient is taking ciclosporin after a liver transplant
• Children needing a liver transplant may have delayed tooth eruption and discolored/hypoplastic teeth

Dental Neglect

• Neglect
• Poor oral hygiene
• Increased caries
• Increases in inflammation/periodontal disease
• Lack of professional dental care

Sialosis

• Enlarged sides of face

Gingival Overgrowth

Dental Management

• Increased bleeding risk
• Risk of poor wound healing and infection
• Problems metabolizing drugs, for example, local anesthetics
• Infection control: Staff vaccinated
• Lifelong immunosuppressants: risk of infection, may need antibiotics
• Reducing dose of local anesthetic
• Use articaine instead of lidocaine
• Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs)
• May not be able to metabolize certain drugs, including antibiotics like tetracycline

Dental Management

• Prevention
• Oral hygiene instruction (OHI)
• Diet analysis and advice Alcohol cessation Smoking cessation
• Fluoride supplements